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Substance Abuse in Pregnancy. Sophia Y. Feng , MD Family Medicine January 12, 2010. Case. 30 yo G3P0020 p/w CTX, VB, FM, no LOF, accompanied by an older male (friend of FOB) No prenatal care

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substance abuse in pregnancy

Substance Abuse in Pregnancy

Sophia Y. Feng, MD

Family Medicine

January 12, 2010

slide2
Case
  • 30 yoG3P0020 p/w CTX, VB, FM, no LOF, accompanied by an older male (friend of FOB)
  • No prenatal care
  • Admits to heroin use 5 weeks ago, EtOH during pregnancy, cigarette use, Utoxpositive for cocaine
  • Restraining order against FOB who lives in Florida
  • 10/10 pain, screaming, moving around the room, naked, unable to sit still for anesthesia to put epidural, whispers “Get me something for this pain” to the “friend”, positive track marks on arm
  • Pediatrics present at delivery
  • Social work consult requested
introduction
Introduction
  • 4% of pregnant women use illicit substances
  • Half of substance abusing women continue using during pregnancy
  • An even larger proportion abuse tobacco or alcohol
  • Many use more than one substance
  • Pregnant women typically highly motivated to modify behavior to help their unborn child
  • Many resume substance use postpartum
screening
Screening
  • Substance abusers come from all socioeconomic statuses, ages, and races
  • Denial – guilt, fear of legal consequences, loss of custody of children
  • History taking, maternal testing after informed consent, neonatal testing – urine, blood, hair, saliva, sweat, meconium
  • Be sensitive and respectful in interviewing
  • Ask about frequency, time of last use, route of administration
risk factors
Risk Factors
  • Late prenatal care
  • Missed prenatal visits
  • POBHx: miscarriage, IUGR, premature birth, abruption, stillbirth, or precipitous delivery
  • Child with neurodevelopmental/behavioral problems
  • Child not living with mother or involved with ACS
  • History of drug related issues (pancreatitis, abscess, endocarditis, suspicious trauma)
  • Encounters with law enforcement
management
Management
  • Counseling
  • Social services
  • Testing for STDs
  • Frequent prenatal visits, education
  • Early ultrasound
  • Antepartum fetal surveillance
  • Informing pediatrics of possible neonatal withdrawal
substances
Substances
  • Alcohol
  • Tobacco
  • Marijuana
  • Cocaine
  • Heroin
alcohol
Alcohol
  • No level is safe
  • Spontaneous abortions, stillbirth due to fetoplacentaldysfunction, small for gestational age
  • ADHD, oppositional defiant disorder, conduct disorder
  • Binge drinking – Ψ disorders in adult offspring
  • Future drinking problems in adult offspring
  • Fetal Alcohol Spectrum Disorder (FASD)
fetal alcohol syndrome
Fetal Alcohol Syndrome
  • CDC diagnostic criteria, requires all three:
    • Growth problems
    • Facial dysmorphia
      • smooth philtrum,
      • thin vermillion border
      • short palpebral fissures
    • CNS abnormalities
tobacco
Tobacco
  • Impaired O2 delivery, nicotine-induced vasospasm, carbon monoxide, other chemicals, chromosomal instability, lung development
  • Preterm delivery, low birth weight (<2500 g), small for gestational age, PPROM, placenta previa, abruption, IUFD
  • SIDS, asthma, otitis media
  • Idiopathic mental retardation, ADHD
  • Obesity and diabetes in adult offspring
  • Smoking and use of nicotine substitutes in first 12 weeks, slight risk of congenial malformations
  • Pharmacotherapy for those who are unlikely to quit
  • Interestingly, decreased risk of preeclampsia
marijuana
Marijuana
  • Most common illicit substance used in pregnancy
  • Detectable in urine for weeks
  • Adverse effects inconclusive: association with sleep disturbance, hyperactivity, inattention, poorer visual problem-solving skills and delinquency
  • Small head circumference?
  • Strongly associated with concomitant use of cigarettes and alcohol
  • Decreased intelligence testing scores
  • leukemia, rhabdomyosarcoma, astrocytoma
cocaine
Cocaine
  • Crosses the placenta and fetal blood-brain barrier
  • Vasoconstriction, hypertension, may mimic preeclampsia
  • Spontaneous AB, prematurity, abruptioplacentae, fetal death, decreased growth (birth weight, length, head circumference), neonatal tachycardia, cerebral infarction
  • “crack babies” – jittery/tremors, high-pitched cry, irritability, excessive suck, hyperalertness, autonomic instability
  • Associated with delayed cognitive, language development?
  • Beta-blockers contraindicated
heroin
Heroin
  • Preeclampsia, 3rd trimester bleeding, malpresentation, nonreassuring fetal status,meconium, low birth weight, IUFD, prematurity
  • Neonatal abstinence syndrome (NAS) – increased autonomic reactivity, withdrawal symptoms begin 24 hours after birth, 40 hours with methadone or buprenorphine
  • Prematurity – reduced risk
  • Supportive therapy
  • Psychomotor and neurologic abnormalities, SIDS
  • Adverse developmental outcomes?
  • Methadone treatment used in pregnancy, not associated with birth defects
  • Buprenorphine, good alternative
what can we do
What can we do?
  • Ask – at each visit
  • Advise - cessation
  • Assess - willingness
  • Assist – establish a plan
  • Arrange – follow up, referrals, support
references
References
  • “Alcohol intake and pregnancy”
  • “Smoking and pregnancy”
  • “Substance use in pregnancy“
  • “Infants of mothers with substance abuse”

-www.uptodate.com

  • “Drug use in pregnancy”
  • “Neonate opidate withdrawal”

- Dynamed